By Jacqueline H. Abernathy, Ph.D.
Switzerland has an unlikely tourist attraction — one where those who visit never leave — and it draws Germans to it more than visitors of any other nationality. It is called the Dignitas clinic, and Germans represent 44 percent of foreign-nationals paying the staff to help them commit suicide. This is more than double the next most common nationality of suicide tourists, British citizens, who constitute 21 percent of the euthanasia clinic’s international business. Death as a paid service is such a concern to the governments of Germany and the United Kingdom that both have recently voted on legislation to ban this practice. Britain overwhelmingly rejected killing outright this September with a vote of 330 to 118 against legalizing assisted suicide.
This is the first regulation amidst legal ambiguity regarding suicide in Germany. It is important to note that, like many countries, there have been no laws in Germany that have expressly prohibited assisted suicide, though physicians who assisted in the practice received scorn from affronting medical ethics. Traditional medical ethics historically has condemned doctors doing any harm, even harm that is requested by the patient, and in fact the classical Hippocratic Oath forbids it, noting, “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.” Many modern oaths still condemn euthanasia, even the referral for it. Lawmakers in the Bundestag, the German parliament, lacked the votes to ban the practice completely just as pro-euthanasia lawmakers lacked the votes to codify the practice as a human right. The result was the compromising middle ground: restricting just assisted suicides performed by associations, also known as “businesslike assisted suicide.”
Potential implications of this vote must consider that the status quo allowed assisted suicide with no regulation, although the medical establishment frowns upon it. Nonetheless, the intended outcome of protecting patients from opportunistic, profit-minded predators who exploit those at their most vulnerable (and also safeguarding Germany from becoming the next suicide tourist destination) may be overshadowed by several pitfalls in the new law. The primary pitfall is the inadvertent publicity that assisted suicide is legal in the country, as well as the newfound legitimacy this lends to the practice. Indeed, this will shut down Germany as a potential suicide tourism destination in the future, even as the prevalence of the practice appears to be growing. However, foreign nationals still may travel to other nations like Switzerland or Holland, just as Germans have been doing. And now Germans are aware that they no longer must travel at all.
Furthermore, there is an additional concern that this new law misrepresents the practice of assisted suicide as potentially free from financial coercion. Indeed, the law does inhibit predatory organizations from specializing as medical hitmen for hire. Yet the idea that German law eliminates financial coercion remains a dangerous illusion. Health care is almost always more expensive than killing and killing is a quick, convenient and cost-effective alternative to compassion.
It also has perhaps increased the vulnerability of German citizens, in spite of the implied intent to help citizens by regulating assisted suicide in the absence of any oversight. The government could still reap any cost-savings, despite how the German healthcare system is financed with its statutory “sickness fund” system, because the German government relies upon private insurers to deliver treatment. Killing is simply cheaper than caring. Here in the United States, a woman enrolled in the government insurance plan for Oregon was denied her request to fund the cancer treatment she sought, but was offered “free” assisted suicide. Regardless of who funds health care — self-funded, charity-funded, government-funded, private insurance or any composite of the above — there is often a financial advantage for the funder if the patient chooses “to end it all” rather than incur expenses for treatment until the natural end comes, as death inevitably comes for everyone.
Furthermore, the personal risk for both those with means and without means endures. Even if the medical establishment continues to frown upon physicians who assist in suicide, in the final analysis the Bundestag affirmed and promoted its legality. Beyond health care expenses, there are those heirs to patient property who have reason not to see their inheritance spent on pain control, nor wish to wait for a natural death to inherit their share of the estate. Suicide tourism involves the costs to travel internationally as well as thousands in fees, meaning that those who have availed themselves of this service have at least the means to make a one-way trip to Zurich and likely have property to bequeath. Germany has now made it easier for the rich to die richer, to please their heirs. And even for the destitute, coerced by their financial woes, these now have an opportunity to self-destruct without the travel obstacle and without the additional expenses that associations like Dignitas demand for membership.
Striking the supposed business motive may appear to protect patients from predatory and opportunistic associations who would profit from assisted suicide, but in reality in many ways it increases the vulnerability of Germans most in need of protection. Assisted suicide is simply so dangerous that it cannot merely be regulated. Policies that attempt to inhibit and prevent suicide are well-meaning and serve a vital purpose in public health by attempting to limit casualties. Nonetheless, efforts in Germany, as elsewhere, must continue to strive for total protection of citizens against self-destruction.
Jacqueline H. Abernathy, Ph.D. is a bioethicist.